Project Summary/Abstract Surrounded by a cacophony of sounds, severely ill patients, frustrated family members, and frequent interruptions, emergency physicians provide care in an incredibly complex environment and report significant amounts of job-related stress. Stress has been shown to negatively affect decision-making, technical skills, and team interactions, and therefore has the potential to negatively affect patient care and patient outcomes. Prolonged occupational stress also contributes to burnout, and emergency physicians leaving the specialty, thereby limiting available providers to care for patients. While emergency physicians have long reported work-related stress, little is known about the true stress- inducing factors of the emergency department work environment. Additionally, simulation is an important component of education for physicians-in-training, however simulation as it is used in healthcare usually features low psychological fidelity, or the ability of the simulation to evoke the same psychological response as the true environment. Psychological fidelity has been linked to improved transference of skills learned in simulation to practice in real-world environments. In Specific Aim 1 we will begin the work of elucidating the stress-associated factors of the emergency department environment by using an innovative method, developed from strategies used in other high-risk industries such as aviation, of using unobtrusive physiologic response monitoring of physicians at work to evaluate stress-inducing factors. The factors discovered here will be further evaluated and validated using semi-structured interviews and qualitative methods in Specific Aim 2, with a resulting robust taxonomy of stress- associated factors in the emergency department work environment. This taxonomy will be used in Specific Aim 3 to develop preliminary simulation scenarios with improved psychological fidelity as the final outcome of this project. These scenarios will serve as the foundation for a follow-on proposal in which we will develop stress-management techniques and evaluate these in a randomized, controlled fashion in the setting of the improved simulation scenarios.